Uterine Fibroids

Common symptoms of fibroids include:
Heavy periods – due to increased uterine volume and endometrial surface area if impacting the inside of the uterus. They also result in an inability for the uterine muscle to contract properly, due to their space occupying nature, and hence the uterus is unable to reduce menstrual flow to stop the period, resulting in long and heavy periods.

• Pressure related symptoms.
• Issues with urination if they are large and located close to the bladder.
• Problems with getting pregnant and fertility.
• Problems with keeping a pregnancy if impacting the endometrial cavity.

Classification of fibroids

All fibroids grow within the muscle of the uterus, but their location is important as:
1. It dictates the issues and symptoms that they will cause.
2. It dictates the best surgical technique that they will be amenable to for removal.

All fibroids grow within the uterine muscle. The old classification of fibroids used to be:
– Submucosal – growing into the uterine cavity.
– Intramural – growing within the muscular uterine wall
– Subserosal – growing outside uterine surface

There is a newer classification of fibroids called the FIGO (The International Federation of Gynaecology and Obstetrics) classification of fibroids and this is Dr Wetherell’s preferred classification system, as it gives the surgeon so much information about the exact location of a fibroid, and eliminates any ambiguity. The location of a fibroid is critical to the approach of surgical treatment (see image below). For example, a Type 0 fibroid would be better suited to hysteroscopic resection, whereas a large Type 1 fibroid may be better suited to a laparoscopic myomectomy for complete surgical excision. It is this nuance and care that is taken by Dr Wetherell to ensure the correct procedure is undertaken to provide you with the the most favourable surgical and symptomatic outcome.

Management

If a patient is asymptomatic of fibroids with none of the symptoms listed above, then they do not necessarily need any management of their fibroids. Also, if a patient is post menopausal and has had a stable, long term fibroid that they have no symptoms from, this also does not necessarily need any management. After careful review of the entire case by Dr Wetherell, fibroids generally only need management if they are causing symptoms or infertility.

Medical management

There is limited medical management of fibroids. Whilst hormonal management, such as the COCP, POP or Mirena IUCD can potentially reduce the bleeding associated with fibroids, the issue is a structural one. Depending on the location, total uterine volume, surgical suitability of the patient, and comorbidities, if a patient is symptomatic of fibroids then they most likely need surgical management to restore the anatomy and fix the cause of the heavy bleeding or mass symptoms.

Procedural management

There are other ways to manage fibroids that are non-surgical. These procedures include:

Uterine artery embolization:

• Radiological procedure where the uterine artery is “blocked off” and therefore the blood supply to the uterus is reduced and the fibroid may shrink.
• This is not suitable for patients who wish to get pregnant, as effects on fertility are not well determined.
• I would reserve this for patients who are not good surgical candidates or those who want to avoid surgery.

MRI guided focused ultrasound (MRgFUS)

• Uses MRI to localise the fibroids and provide targeted ultrasound heat energy to cause cell death in fibroids.
• This has varying results as it does not remove the fibroids, resulting in higher rates of recurrence of fibroids and clinical symptoms.
• Currently, it is no longer available publicly or privately in Melbourne.

Surgical Management

Overall, surgical management can be divided into two broad categories:

1. Hysteroscopic resection – “removal from below”

• This is reserved for Type 0 or 1 fibroids (submucosal or intramural impacting the endometrial cavity) which can be “accessed from down below” from the uterine cavity via a camera called a hysteroscope and using a device called a resectoscope, which removes small pieces of the fibroid under vision.
• This is usually reserved for fibroids <4cm in diameter, as any larger than this the resection will take too long, and if it is a Type 1 fibroid a large portion of the fibroid will not be removed in its entirety.
• This is a day procedure and usually takes anywhere from 30-60 minutes.
  (see video in Surgeries page)

2. Laparoscopic myomectomy – “removal from above”

• This is suitable for all other types of fibroids and larger fibroids >5cm.
• It provides complete excision via a keyhole approach. The largest incision is 1.5cm in the belly button. It provides excellent cosmesis and minimal pain and prompt recovery
• I usually divide this operation into 3 key components:
  i) Myomectomy
  ii) Suturing of the uterus in layers – usually 3 layers
  iii) Power morcellation of the fibroid in a bag
• This is a procedure that I commonly perform and I would say it is my favourite minimally invasive procedure as it has such great long lasting results in my patients.